Age Related Macular Deterioration`

Age related macular degeneration (AMD) is a condition which occurs commonly in people over 60 years of age and is one of the most common causes of poor vision in elderly Europeans.

Lining the inside of the eyes is the retina, which is a photo sensitive layer comparable to a photographic film. A tiny 5mm diameter part of the retina, called the macula, is responsible for sharp visual acuity and colour vision.

Several degenerative processes may affect the macula. In the case of age related macular degeneration, increasing age is the main causative factor.

The degeneration involves weakening of certain supportive layers in the macula and the accumulation of metabolic waste products. These yellowish white deposits resemble calcification and are often referred to as such.

The most common complication is the development of new, abnormal blood vessels which are fragile and easily leak and bleed (so-called neovascular membranes).

The early symptoms of macular degeneration are deterioration of visual acuity and distortion of images. AT WORST complete loss of central vision may occur, with the patient seeing a dark spot central to the visual field.

Darkness and light and forms may still be well differentiated and a measure of colour vision may be retained. Both eyes are usually affected, one eye typically more advanced that the other.

On the other hand macular degeneration per se never causes total blindness and patients often function well and independently within familiar surroundings. Unfortunately driving a motor vehicle is mostly not possible.

Therapeutic options available to treat this condition are very limited. Neither spectacles nor surgery or medication can stop the degeneration.

Neovascular membranes may under certain circumstances be treated with laser. Surgical removal of these membranes is being done in selected cases with limited success.

Generally vision is monitored with a Amsler chart and sudden significant changes in visual acuity and/or distortion on the Amsler chart call for evaluation and possible treatment by an eye specialist. Spectacles and so called low vision aids (including various magnifiers) are also of some value.

Lastly, it is important to note that age is virtually the only causative factor and no amount of reading, sewing or other activities add to this.

Once this condition has been diagnosed, it is equally important to note that there is no limitation to the use of your eyes and you should confidently engage in any activity your eye allows.

Cataract Surgery

What does Cataract Surgery involve ?

Microsurgical removal of the cataract is done under general or, more often, local anaesthetic. The cataract is removed via a small incision using ultrasound (SONAR) or mechanical instrumentation. An artificial lens is normally implanted and the incision may be closed with very delicate sutures, which may or may not be removed in time. Currently, the latest techniques requiring no sutures, are preferred whenever possible.

What is a Cataract?

Cataracts may be caused by a multitude of conditions including eye diseases, systemic diseases, heredity and trauma, but by far the majority occur as part of the normal ageing process in people above the age of 55 years. There is no known method of preventing or reversing cataract formation

Cataracts are diagnosed through comprehensive ophthalmic examination and are not to be confused with the more obvious superficial growth on the eye surface, the so-called pterygium

Cataracts are usually slowly progressive and surgical removal is the only treatment and is recommended once normal daily activities are impaired

Pre- and Postoperative Instructions

Optimal general condition pre-operatively is important. Any infection (of the eye, bladder, respiratory tract) or septic wounds pose a risk to the operated eye and should first be treated. Systemic conditions such as diabetes, hypertension, heart failure and asthema should be well controlled. A timely visit to your general practitioner a week in advance of surgery is advisable.

Please discontinue all eye cosmetics and contact lenses 72 hours prior to surgery. Anticoagulants (e.g. Disprin, Warfarin) should not be discontinued, but coagulation status should be monitored and optimalised.

Eye drops prescribed after the operation should be instilled by pulling the lower lid away from the eye as follows: One drop 4 hourly for seven days and as directed thereafter only during waking ours (06:00-22:00). Wash hands with soap and water before administering drops. Do not buy additional drops unless prescribed. The eye may be left open indoors, but protect with an eye pad from windy and dusty conditions and cover with a plastic eye shield during sleep for the first week.

Prevent water from entering the eye for the first week. (Do not swim or shower)

Pain tablets are only for the first two days after the operation. Any subsequent lasting PAIN, REDNESS or DIMMING of VISION should be reported to your ophthalmologist promptly. This is most important.

Acquisition of glasses will be arranged during the last post-operative visit.

Occasionally, vision may dim slowly weeks to years after the operation. It may be necessary to clear opacification of residual lens membrane with laser as an out patient procedure requiring only a few minutes and no anaesthetic.

Diabetes and the eye

Diabetes mellitus (Type 2 Diabetes) affects the eye through premature cataract formation, fluctuating refraction (spectacle requirements) and so called retinopathy. Retinopathy implies malfunction of the nerve and sensory layer of the eye due to damaged small blood vessels and manifests in three basic forms:

early background changes which seldom affect vision and are relatively innocuous.

maculopathy which impairs vision.

proliferative retinopathy, the complications of which may have catastrophical visual consequences.

Optimal control of diabetes through diet, oral medication or insulin injection is very important and may delay, but not necessarily prevent the onset of retinopathy.

Systemic hypertension (high blood pressure) should be well controlled, as should high blood cholesterol levels.

Complete ophthalmic evaluation shortly after the initial diagnosis of diabetes is advised. Depending on the findings at this stage, regular follow-up visits will be scheduled to monitor progression. Since treatment may be required in the presence of absolutely normal vision, these follow up examinations are most important.

Once vision threatening retinopathy is noted, different forms of laser treatment are employed to improve vision or prevent further complications.

Some of these complications (e.g. vitreous haemorrhage, membrane formation or retinal detachment) may require surgical treatment.

The keys to preservation of vision are:

early base line evaluation.

regular follow-up examination (as scheduled or promptly when new symptoms appear) to monitor any progression.

optimal control of the diabetes

Dry Eye Syndrome

Dry eyes or so-called keratoconjunctivitis sicca is a common condition affecting patients of all ages. Although not a disease, it represents poor tear function caused by disfunction of one or more of the components of tear production and/or dynamics.

The lids play a key role because of:

their blinking action and

the oil glands contained in the eye lids, which are responsible for the critical oily component of a normal tear film.

Burning or a gritty feeling of the eyes, often accompanied by episodes of tearing are the most common symptoms. Associated heaviness of the eyelids and a precipitate or even frank discharge upon waking is common. Intermittent blurring of vision and even episodic double vision may occur.

The corner stone of therapy is the frequent use of artificial tear supplements. Initially very frequent applications may be called for, but as the eye surface recovers, symptoms may be controlled by applying drops two to three times per day. The eyelids are often affected by so called seborrheic eczema, for which scrubbing of the eyelid margin with baby shampoo, morning and evening, is necessary. Depending on the condition of the eye and lids, a short course of antibiotics and cortisone drops may be used. If poor oil gland function is prominent a low dose of oral antibiotics for plus minus four weeks is often recommended. Although the condition cannot be cured, symptoms may be dramatically relieved by the above measures. Aggravating circumstances, for instance wind, heat, air conditioning or extended periods of reading or watching TV and the use of soft contact lenses can be avoided or otherwise attenuated by timely and frequent use of artificial tear supplements.

Plugging of the tear ducts may further reduce the need for tear supplements.

Eyelid Hygiene

Scrub eyelid margins (above and below) thoroughly with a cotton bud soaked in the above solution. Repeat morning and evening.

Glaucoma

Glaucoma is an eye disease characterised by typical optic nerve damage and concomitant visual field loss.

The most common form of glaucoma, Primary Open Angle Glaucoma, occurs mainly in persons 40 years of age and older. It tends to run in families, is more common in diabetics and nearsighted individuals and is characterised by increased intra ocular pressure. Other forms of glaucoma may be congenital or secondary to inflammation, injury or other diseases of the eye.

Glaucoma normally develops insidiously without early signs or symptoms. Slowly progressive damage may only manifest much later as loss of peripheral or even central vision. On the contrary, the much less common Acute Angle Closure Glaucoma is normally diagnosed early due to sudden onset of blurred vision, pain, redness and sometimes nausea.

Glaucoma is best diagnosed or ruled out by thorough ophthlmological examination, particularly after age 40 and especially in the presence of nearsightedness, diabetes or a family history of glaucoma.

If treated early and effectively, glaucomatous visual loss may be limited or halted. Initial treatment normally involves eye drops. Inadequate control may necessitate laser treatment or eventually surgical treatment.

Visual loss from glaucoma is usually irreversible and permanent. As timely medical or surgical intervention may effectively preserve vision, early and regular eye examination is most important.

Laser Eye Surgery / Refractive Surgery

What is Laser Eye Surgery?

Laser eye surgery is a short operation whereby the cornea (window of the eye) is dissected with a special keratome (cutting instrument) and then modified/remodelled with laser.

The laser ablation is individualized for each patient by the doctor and controlled by computer, according to internationalized statistical standards.

Myopic or short-sighted patients, as well as far-sighted patients, often have a life long dependency on spectacles and/or contact lenses. For various reasons these patients may wish to dispose of their spectacles and contact lenses.

To be eligible for the treatment you should:

Be at least 17 years old, with a refraction having remained stable for at least one year (there is no maximum age, but presbyopia – a condition that many times requires bifocals in patients over 40 years of age – should be considered)

Have no active eye disease

Be in good health

Risks of Lasik:

Lasik is entirely an elective procedure. As with any medical procedure there are risks involved.

Lasik cannot always produce 20/20 or even 20/40 vision. Lasik does not correct presbyopia – a condition that many times requires bifocals in patients over 40 years of age. After Lasik, some patients may require reading glasses for close up work.

Complications:

Infection – extremely rare.

Lasik patients may suffer from night vision effects, similar to htose experienced with contact lenses.

Significant regression (3-4%). Usually the same group as the corneal haze. Usually responds well to re-treatment.

Long term stability. Refraction changes after 6 months tend to be small and to approach a final value in an asymptomatic fashion.

Some patients complain of a dry eye, light sensitivity, blurry vision at times. This will resolve as the eye heals. Artificial tear supplements are used routinely after Lasik for one to six months.

In some rare cases it may be necessary for a re-treatment, typically 6 weeks to 6 months after the initial procedure.

Preparing for Laser Surgery:

Soft contact lens wear should be stopped at least 3 days prior to surgery.

4-6 weeks prior to consultation, hard contact lens wearers will be required to remove lenses and wear soft contact lenses or glasses for this period.

3 days prior to surgery wearing of all cosmetics should be stopped. Even with the utmost care taken when removing make-up, fine particles are still left and can be seen under magnification.

On the day of the surgery, dress warmly as it is very cold inside the theatre.

Post-operative Care:

On the day of surgery, take your medication as directed. You may bath, but you MAY NOT wash your hair.

See your ophthalmologist the day after surgery as directed and DO NOT remove eye patches prior to the consultation. Continue with drops as directed.

DO NOT wear any make-up for the first week after surgery

DO NOT rub your eyes.

DO NOT play any contact sport for the 2 weeks after surgery, and wear protective glasses for a few weeks after surgery.

Take care when washing your face and hair for one week after surgery to avoid getting soap in your eyes.

Avoid swimming for 4 weeks after surgery.

On the day of your Surgery ...

Please leave all valuables, i.e. jewellery, watches, etc. at home.You may have to wait some time prior to being taken to the theatre, so bring along a book, some handwork and plenty of patience.It is of utmost importance that you bring the following documentation with you:

Your ID Document and that of the Medical Scheme main member:

Your Medical Aid Card

The Authorisation Number and the name of the person who assisted you at your Medical Aid (obtained prior to arriving at the Institute and Medical Forum Theatre)

If you are having a local anaesthetic – feel free to have orange juice or tea and toast before coming to the Institute and Medical Forum Theatre.

If you are going to have general anaesthetic:

Have nothing to eat or drink for:

Adults: 8 hours prior to the operation

Children: 6 hours prior to the operation

Arrange to have transport home after the operation. Patients may not drive themselves home after the anaesthetic.

All patients under the age of 18 years, must be accompanied by an adult, next-of-kin or legal guardian to sign the necessary consent forms

If you are unsure regarding which of your usual medications may be taken, please contact your ophthalmologist’s practice prior to surgery.

Generally speaking, a post-operative consultation is required the day or week after your procedure.

Please ensure that this appointment is met.

Pterygiums

A pterygium is a superficial growth, normally slowly advancing from the conjunctiva (white of the eye) onto the cornea (the clear tissue over the coloured iris).

Pterygiums are often confused with cataracts, but have no resemblance to cataracts, which are opacities in the lens of the eye. They should however, be differentiated from other superficial growths which may be benign or malignant.

The only proven cause of pterygiums is exposure to ultra-violet light, which damages superficial tissue. Pterygiums could be regarded as scar tissue formation in response to this damage.

Pterygiums normally progress slowly towards the centre of the eye, but may take many years before actually threatening sight.

Pterygiums occur in all age groups and are more common in people spending much time outdoors. They may be asymptomatic or, when more advanced, cause itching, burning, grittiness and redness. There is a frequent association with poor tear function.

Small symptomatic pterygiums are often managed satisfactorily with short courses of cortisone drops and artificial tear supplements. Surgery is considered when conservative treatment fails or when pterygiums are cosmetically unacceptable or sight threatening.

Surgical removal of a pterygium is a relatively low risk operation as it is limited to the surface of the eye. However, considerable discomfort is experienced post-operatively by most patients. Pterygiums have a very strong tendency to recur. Any one of a number of preventative techniques to curb recurrences may be routinely employed at the time of surgery.

Keeping the eye closed for the first 10-14 days after the operation usually makes it more comfortable. Dust, water, shampoo and other foreign matter should be avoided. Drops are applied 4 times per day for the first 2 weeks. The eye usually remains conspicuously red for a few weeks and then returns to a normal white appearance after 6-8 weeks.

Squints in children

Squint is a vast topic and only the most common forms of squint in young children are referred to briefly. A squint or strabismus may be primary (the most common kind) or secondary to an underlying cause.

ANY squint, whether constant or intermittent, occurring in a child after the age of three months, should always be properly assessed by an eye specialist.

The eye specialist’s first task is to exclude underlying (sometimes serious) causes of strabismus. These may include congenital conditions, rare neurological syndromes, brain tumors, birth injuries and localized eye diseases. Fortunately these causes of strabismus are by far the minority.

Secondly, it is of paramount importance to ascertain whether the young child’s vision is normal and equal in both eyes. Poor vision in one eye may cause a squint. Equally important is the fact that an otherwise normal eye may loose visual ability and become lazy or amblyopic, because of a squint. This danger exists until the age of roughly 9 years.

If it is diagnosed early, an amblyopic eye may be stimulated with reasonable success to improve and normalise visual ability. After the age of about 9 years visual ability is permanently fixed and can not be manipulated.

All the above information can only be obtained by thorough and sometimes repeated ophthalmic examination, which may even require examination under anaesthetic.

A dilated examination of the eye and cycloplegic refraction (having enlarged the pupils with eye drops) is an essential part of such an assessment. If a significant refractive error (spectacle error) is present, its causative role should be assessed by a trial period of wearing the appropriate spectacles. A purely refractive accommodative squint will be eliminated by the spectacles alone.

In a second group of children the spectacles may reduce but not eliminate the squint. If the residual squint is significant it may be surgically corrected. After surgery the use of spectacles will still remain essential.

In a third group of children a refractive error is not relevant and surgical repair alone should eliminate the squint.

Although squints are often referred to as being left or right sided, a squint involves misalignment of BOTH eyes and surgical repair is seldom attempted before BOTH eyes have equal and normal visual ability. Likewise, strabismus surgery is often done on both eyes, whether at one or more than one session.

Even after successful surgical or other correction of strabismus the danger of amblyopia remains until the age of approximately 9 years and regular follow up visits should be made regardless of a good cosmetic result.